Now, let's talk about the hisotry of present illness, or the HPI. What is an example of this? An example of this is if you come in and you are seeing a patient for a rash and you introduce yourself and you start asking the patient questions of their history of present illness–when did the rashes start, what does it look like–all of the aspects of the interview from the patient standpoint you are going to record in the history of present illness, and you want to be detailed and concise. This would not be, this would be in a paragraph form so I am going to try and revise this template by the time you see the template, but this would be a sentence or a statement after statement after statement and not lines like this in your documentation, but this is what it looks like on the form.
I would write, 'I'm seeing a 44-year-old Caucasian male who presents today with burning and painful rash for the past 24 hours on the right side of the chest under the right axilla.' So you are seeing what the patient is being seen for. You are seeing what the location is. You are seeing the time frame, and you are seeing some of the description. It goes on to describe the characteristics of the rash. It goes on to tell you what is also happening with the rash is that it is spreading and characteristics of the pain. It is telling you what are the relieving factors such as the patient has tried cold packs or over-the-counter Tylenol. What are other issues going on with the rash or the pain at the rashes site? It started a couple of days ago prior to a breakout, so what are the other things going on are the temporal factors. This is really important in terms of your diagnosis, and the pain is described as a 4/10 moderate burning and stabbing pain. You don't have to put these individually in senses. You might combine this information when you get better and better at history of present illness, but I want you to take the time and try and describe and use all of these different factors, the OLD CARTS so that you can be as descriptive as possible, all right?
What is vital about your history of present illness is that is going to be one of the key points of how you're going to come up with your differential diagnosis and primary diagnosis, so it is very important to be concise. Ask lots of questions and record it in this fashion.